Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heights Rehabilitation And Healthcare Center, The during CMS and state inspections, most recent first.
A Business Office Manager misappropriated resident funds by writing checks to herself, making unauthorized purchases, and failing to follow required procedures for resident fund management. Multiple residents, including those with cognitive impairments and legal guardians, were affected, with items purchased that were not authorized or never received. Staff observed irregularities but did not escalate concerns, and families confirmed they had not approved many of the transactions.
A resident with complex behavioral health and pain management needs did not receive scheduled medications in a timely manner after requesting them during the night. The assigned RN, citing concerns about the resident's agitated behavior, did not administer the medications or seek assistance from other available nurses, resulting in a delay of care and unmanaged pain. Facility policies and individualized care plans were not followed, as confirmed by staff interviews and documentation review.
A resident with PTSD did not have an individualized care plan addressing her specific triggers, such as discomfort with people entering her personal space. Staff were unaware of these triggers until informed by the resident, and no formal interventions or documentation were in place to minimize the risk of re-traumatization.
A resident dependent on staff for all ADLs was found with visibly soiled bedding that was not changed promptly, with a dried brown stain near the wrist area believed to be blood from a recent blood draw. Additionally, a CNA and surveyor observed a large hole with broken tiles in the south wing shower room wall, which had the potential to affect multiple residents using that area.
Two residents with complex medical needs experienced uncomfortably high room temperatures due to malfunctioning air conditioning units. Staff and family members reported that the rooms were hot, with one room measured at over 81 degrees Fahrenheit and both rooms requiring the use of fans and wet blankets. Maintenance and nursing staff were not fully aware of the extent of the issues, and temperature logs were not up to date, resulting in a failure to provide a safe and comfortable environment as required by facility policy.
A facility failed to comprehensively assess and monitor a resident's bruises following a fall. The resident, with a history of cerebral infarction and aphasia, was admitted without skin impairments but developed bruising after a fall. Although monitoring orders were in place, documentation lacked detailed descriptions and progression of the bruises, leading to a deficiency finding.
A resident's medical records were improperly disclosed to an unauthorized family member due to a miscommunication during a care conference. The facility's policy on maintaining the privacy of health information was violated, affecting one resident with severe cognitive impairment.
The facility failed to report and investigate an alleged abuse incident involving a resident with severe cognitive impairment. The resident called the police, claiming staff beat her, but no documentation or investigation followed. The facility's abuse prevention policy requires prompt investigation and reporting of such allegations.
Failure to Protect Residents from Misappropriation of Funds and Exploitation
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property and exploitation, affecting 13 residents with resident funds accounts. The Business Office Manager (BOM) was found to have written checks to herself from resident funds, often without proper authorization or documentation from residents or their legal representatives. In several cases, the BOM purchased items that were not authorized by families or guardians, and many of these items were not found in the residents' possession. The BOM also wrote a check to her father to cash on her behalf, further violating facility policy and resident trust. Multiple interviews and record reviews revealed that the BOM bypassed established procedures for resident fund management, including the division of duties and requirements for receipts and vendor payments. Staff members reported that packages addressed to the BOM would arrive at the facility, and the BOM would direct staff on how to distribute or label the items. In some instances, staff questioned the appropriateness and cost of items purchased, such as expensive electronics and jewelry for residents with cognitive impairments, but did not escalate their concerns to administration. The BOM admitted to writing checks to herself and using her own credit card for purchases, but failed to document family authorizations or maintain proper records for many transactions. Affected residents included those with severe cognitive impairments, such as dementia, and those with legal guardians, as well as cognitively intact individuals. In several cases, families and guardians confirmed they did not authorize the purchases made on behalf of the residents, and some residents reported not receiving the items or not consenting to the expenditures. The facility's internal investigation, supported by police involvement, confirmed that misappropriation occurred, with missing receipts, unauthorized purchases, and funds withdrawn for items not received by residents.
Failure to Provide Timely Behavioral Health and Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan to support the behavioral health care needs of a resident with multiple psychiatric and physical diagnoses, including borderline personality disorder, PTSD, generalized anxiety disorder, severe morbid obesity, and chronic pain conditions. The resident had documented care plans addressing pain management, behavioral symptoms, aggressive behaviors, and psychiatric/mood issues, with specific interventions such as timely medication administration, emotional support, and strategies to minimize behavioral triggers. Despite these plans, the resident did not receive scheduled medications at the prescribed time after requesting them during the night, resulting in a delay of care. On the night in question, the resident requested her scheduled medications at 4:00 A.M., but the assigned RN was on break. Upon returning, the RN did not attempt to administer the medications or seek assistance from other available nurses, despite the presence of additional licensed staff on duty. The RN reported feeling unsafe due to the resident's agitated and hostile behavior, which included yelling and making derogatory remarks. Instead of following up with the physician or nurse practitioner regarding the late medication request, the RN only contacted facility management via text and did not receive a timely response. The resident ultimately did not receive her medications until several hours later, after experiencing significant pain. Interviews and documentation confirmed that other nurses could have administered the medications, and that the RN's failure to do so was not in accordance with facility policy or standard nursing practice. The facility's medication administration policy required medications to be given as ordered, and the behavioral assessment policy emphasized individualized interventions to address residents' needs. The incident was substantiated by medical record review, staff interviews, and disciplinary action taken against the RN for failing to provide necessary care.
Failure to Develop Individualized PTSD Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite the resident's medical record indicating diagnoses of generalized anxiety, borderline personality disorder, major depressive disorder, and PTSD, there was no assessment completed to identify the specific cause of PTSD or potential triggers that could lead to re-traumatization. The care plan only generally referenced psychiatric and mood status but did not specify PTSD triggers or interventions to minimize risk. Interviews revealed that the resident was cognitively intact and independently mobile, and had reported being bothered when people entered her personal space, which was a known trigger for her PTSD. Staff interviews indicated a lack of awareness regarding the resident's PTSD triggers, with both nursing and CNA staff stating they were unaware that proximity could cause the resident anxiety until the resident herself informed them. The Social Services Director confirmed that while a PTSD checklist was completed and triggers were discussed verbally, this information was not documented in the medical record or care plan. As a result, no formal interventions were developed or communicated to staff to address the resident's PTSD triggers, and the facility did not have a PTSD-specific policy in place.
Failure to Timely Change Soiled Bedding and Maintain Shower Room in Good Repair
Penalty
Summary
The facility failed to ensure that visibly soiled bedding was changed in a timely manner for a resident with quadriplegia, tracheostomy status, ventilator dependence, and a gastrostomy tube. Observation revealed a dried, brownish stain approximately 2.5 inches in size on the resident's sheet near the right wrist. The resident was dependent on staff for all activities of daily living and had intact cognition. A registered nurse verified the stain and believed it was blood from a small scabbed area on the resident's right arm, possibly related to a recent blood draw. The Director of Nursing confirmed that linens should be changed when visibly soiled and provided lab results indicating a blood draw had occurred the previous day. Additionally, the facility failed to maintain the south wing shower room in good repair. Observation showed a basketball-sized hole with broken tiles in the lower part of the wall between the shower and bathroom, under the hand sanitizer. A certified nursing assistant confirmed the damage but was unsure how long it had been present. This issue had the potential to affect 35 residents who used the south wing shower room.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, both of whom had significant medical conditions including respiratory failure and tracheostomy status. For one resident, observations revealed that the air conditioning unit in the room was turned off, leaking, and not functioning properly, with wet blankets placed underneath and a fan provided as a temporary measure. The front of the air conditioning unit was removed and lying beside the wall, and maintenance staff were unaware of the malfunction until it was brought to their attention. Nursing staff confirmed the room was hot and the resident was sweating, and the family had reported concerns about the room temperature over the weekend. Documentation showed that the last recorded room temperature was several days prior, and a grievance had been filed by the family regarding the environmental conditions. For the second resident, similar issues were observed with the air conditioning unit, which was only slightly blowing cold air and required the use of two fans in the room. The ambient temperature in the room was measured at 81.4 degrees Fahrenheit. The resident's family also reported that the room was hot and the air conditioning was not working properly. Facility policy required maintaining a comfortable and safe temperature for residents, but observations and interviews indicated that this was not achieved for these two residents.
Failure to Comprehensively Monitor Resident's Bruising
Penalty
Summary
The facility failed to comprehensively assess and monitor scattered bruises on Resident #200, which were discovered following a fall. The resident, who had a history of cerebral infarction, muscle weakness, and aphasia, was admitted to the facility and later discharged against medical advice. Upon admission, the resident did not have any skin impairments, but after a fall on the premises, bruising was noted on the resident's arms, legs, and face. Although there were orders to monitor the bruising every shift, the documentation lacked detailed descriptions, measurements, and progression of the bruises. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the bruising was documented as scattered bruises in the initial fall report. However, the medical record did not provide evidence of comprehensive assessments and monitoring of the bruising. The resident's wife was informed of the bruising, and staff were monitoring it, but the lack of detailed documentation was noted as a deficiency during the complaint investigation.
Unauthorized Disclosure of Resident's Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's medical records. Resident #3, who had severe cognitive impairment and was admitted with diagnoses including malignant neoplasm of the lung and cognitive communication deficit, had her medical information improperly disclosed. The resident's powers of attorney (POA) were the only non-providers authorized to access her medical information. However, the facility mistakenly gave the resident's medical records to her sister, who was not authorized to access them, due to a miscommunication during a care conference. The Licensed Social Worker (LSW) left the records at the front desk for pickup, not realizing the requesting family member was unauthorized. The incident was confirmed through interviews with the POA, the LSW, the unauthorized family member, and the facility administrator. The facility's medical information policy, which mandates the privacy of residents' health information, was reviewed and found to have been violated. This deficiency was identified during a complaint investigation and affected one resident out of a facility census of 125.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure alleged abuse events were reported and investigated appropriately, affecting one resident of five reviewed for abuse prohibition. Resident #19, who had severe cognitive impairment and other diagnoses, called the police on 02/06/24, claiming staff beat her and treated her harshly. The police found no concerns regarding resident safety and left the facility. However, there was no documentation of any related skin assessment, notification to management, or investigation into the allegation. Interviews with the resident and LPN confirmed the incident, but the LPN could not recall notifying management, and no report or investigation was submitted to the Ohio Department of Health Certification and Licensure website. The facility's abuse prevention policy, dated 09/2021, required allegations of abuse to be promptly investigated and reported to relevant government agencies. The Administrator confirmed the findings during an interview. This deficiency represents noncompliance investigated under Master Complaint Number OH00152273 and Complaint Number OH00151735.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Broadview Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks Of Brecksville | 1.5 mi | ★★★★★ | 0 | 0 |
| Avenue At Broadview Heights | 1.9 mi | ★★★★★ | 14 | 0 |
| Regina Health Center | 3.4 mi | ★★★★★ | 2 | 0 |
| Brentwood Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Momentous Health At Richfield | 4.3 mi | — | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.